Healthcare Provider Details

I. General information

NPI: 1396236790
Provider Name (Legal Business Name): ASYA B BUSSIE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2018
Last Update Date: 08/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2622 LORD BALTIMORE DR STE A
WINDSOR MILL MD
21244-2639
US

IV. Provider business mailing address

3202 BLENHEIM RD
PHOENIX MD
21131-2228
US

V. Phone/Fax

Practice location:
  • Phone: 443-629-0696
  • Fax:
Mailing address:
  • Phone: 443-629-0696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: